Demystifying Medicine One Week at a Time

GlassHospital readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.

A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”

First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”

Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.

Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?

I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.

What is radiation proctitis? Is that when your rectum is severely burned as collateral damage by the radiation beam that’s targeting the prostate, and you wind up with rectal pain and bleeding for years? Why yes, it is. That’s in addition to the impotence and loss of bladder control that Ted experienced and had hoped to avoid by foregoing the surgical knife.

Or George, who dutifully came yearly for his digital rectal exam, got his PSA, and when his biopsy showed low grade prostate cancer, opted for surgery. At 64, he told me he’d have rather be dead than live wearing adult diapers his incontinence now thrust upon him.

PSA is a contentious issue. There will always be anecdotes showing that one approach or another is WRONG. The “retrospectoscope” is always 20/20.

But when an entire industry has evolved to profit off of “advanced” treatment for prostate cancer and innocent people are harmed in the process, I get angry.

I took an oath to do no harm. Treatment that causes more harm than the disease it’s designed to cure is tragic.

People will read this post and be outraged. So let me be clear: I’m not saying that NO ONE should get a PSA to screen for prostate cancer. That genie has left the bottle decades ago. I’m saying that the medical and disease-mongering industries owe it to men to be more forthcoming about the risks, benefits, and alternatives to screening.

I try my hardest–and I’m countering years of ‘public awareness’ campaigns. Just ask my Dad, who at not-quite 75 keeps getting the darn PSA year after year despite my advice to stop. “How can a test that detects cancer be harmful?” he always asks me.

7 Comments

Although I agree with much of your “skepticism” and believe we have developed a medical industrial complex that is often profit driven, I believe strongly that the PSA argument as I have seen it is flawed with regard to testing. Not being a medical doctor but a victim of prostate cancer that has studied the disease and its therapeutic options, it seems to me there is an age related window that PSA tests should and do have an appropriate utilization/functionality (approx. 50 to 65 or 70 yrs) and then there is a window where it does become somewhat superfluous due to the less aggressive nature of the disease the older the patient is afflicted with it. It is a matter of appropriate utilization of health care interventions which is where our system seems to fall down on so many basic levels because the industry is profit driven (and litigious). A single payer system (and tort reform) would abrogate much of these issues but, even with changes of this nature, let’s not throw the baby out with the bath water when offering appropriate measures to prevent or limit the impact of disease. Although I understand your statement requesting “the medical and disease-mongering industries owe it to men to be more forthcoming about the risks, benefits, and alternatives to screening.” I think it more appropriate to understand where the test is best employed and then have the “medical and disease mongering industries” honestly and without bias inform the patient of the risks, benefits and alternatives to treatment. I say this because after visiting urologic surgeons (both robotic and classic), radiation oncologists, and cryosurgeons, each and every one of them thought they were best suited to provide treatment of my cancer. Having failed my initial therapy and now dealing with “salvage” therapies, I wonder, who would really have been best suited to treat my cancer and did I just listen to the provider with the best sales pitch?

Exactly. It’s that sales pitch smorgasbord that caused you harm. Me and my primary care colleagues are also to blame–for not being better at knowing the numbers, understanding the therapeutic options, and our patients’ preferences.

I suspect a number of your regular readers won’t appreciate what you have tried to relate/share with them.
Honestly, very well done. Your readers, particulary those men over the age of 50, and their partners, owe you a debt of gratitude.
john

I like the way the author of the column you linked to claimed that if his patient had rolled over and done as he was told, then it would have been “our decision”, “doctor and patient working together” – but not if things happen as the patient prefers. A bit of Orwellian language there. It would also be nice if he acknowledged that other patients who refused the PSA in the face of similar pressure continue in good health, continence and an active sex life.